Acute appendicitis

“Science is built of facts the way a house is built of bricks: but an accumulation of facts is no more science than a pile of bricks is a house”, wrote the mathematician Henri Poincare. However, as surgeons and doctors, we have to face and consider our own “facts”. We are ageing! This is the first fact. From a global perspective, it is estimated that the number of people over 65 years old will increase from 5234 million in 2010 to more than 1.5 billion in 2050 and, currently, about 33% of hospital stays and 41% of hospital costs are attributed to patients over 65 years old. As an example, more than 20% of the Italian population is over 65 years old and this percentage is expected to rise to 34% by 2050. Over the last 20 years, life expectancy in the country has increased from 78 to 80 years for men and from 84 to 85 years for women. About 20% of the elderly and 6% of the country’s total population are now over 80 years old. Second fact: when we think of the elderly, our first thought is chronic medical illness, but it is estimated that 21% of the total population over 60 will need surgery, compared to only 12% of people in the 45–60 age group. Third fact: we are all well aware of the advantages of laparoscopy in planned surgical procedures, which include elderly and frail patients. However, there are many doubts about emergencies: people over 70 who undergo an emergency laparotomy have a hospital mortality of 21.4%, and older patients, especially octogenarians, have worse outcomes with up to 44% mortality reported. Fourth fact: an ageing population will put greater financial pressure on elderly care systems. And in an era of budgetary restrictions, this has to be taken into careful consideration. Fifth fact: we continue to use the term “elderly” only in a chronological sense: 65 years old continues to be adopted as a threshold for old age. This can no longer be the case, just as it can no longer be just a number (age) to define a person's situation. That is why it is better to use and talk about, and define, frailty. Sixth fact: last but not least, it is no longer the time for the one-man show; surgeons cannot and must no longer ignore multidisciplinarity, especially in the medical profession. These are the facts. However, on their own, these facts are not science. “… As doctors and surgeons, our mission is to treat patients to the best of our knowledge and expertise. The exponential knowledge eruption and the nearly daily skill-related technology advances in minimally invasive surgery make it more than ever mandatory that we, surgeons and doctors, humbly examine, analyze and objectively audit our own practice…we have to recognize and discard our acquired biases, and base our diagnostic procedures and surgical therapy on ‘hard’ evidence…” It is still correct, timeless, and contextual what Dr. Fingerhut wrote. So these were the ideas that led us to be the Editors of a book about the laparoscopic approach in emergencies in elderly and frail patients. We tried to work on it with a multitasking approach, involving not only surgeons but also anaesthetists, internists, nurses, and radiologists. As this is an indisputable fact, only together, we could try to summarize the facts in science. Without forgetting ethics! The idea for this book was born at the beginning of 2020, and in the meantime another worrying fact has emerged, the SARS-CoV-2 (COVID-19) infection. There is no real evidence, especially regarding surgery, about this “worrying fact”. However, we could not overlook it, especially considering that our elderly were significantly affected during the first wave. On the contrary, in the second wave, younger people became frail. We have tried to answer the questions listed above, which we want to share with everyone. Perhaps “forcing” the meaning of the Aristotelian syllogism a bit: if the safety and efficacy profiles of laparoscopy in the elderly and frail patient have been confirmed, then it is even more true in the non-elderly and non-frail patient.